The purpose of this brief advisory is to highlight risk issues — documentation and consent — associated with recent reimbursement expansions created by the Centers for Medicare and Medicaid Services (CMS). More comprehensive analysis of the changes, including rules, limitations, and other specifics is available at https://www.cms.gov/newsroom/.
Background
The Digital Revolution has changed and is continuing to change medicine. There are many drivers of these changes: digital/technological advancements, changing demographics, and societal shifts to digitization. Simply put, we function and communicate more via remote-utilizing technology. In response to this changing landscape, CMS modernized its Medicare physician payment plan and quality reporting program effective January 1, 2019. Reimbursement opportunities for communications-based services, also known as telemedicine and virtual care, have been expanded, which will have a corresponding effect on the associated risks.
Highlighted Aspects of the Medicare PFS Changes
Reimbursement was expanded for technology and communications-based services such as telephonic, internet, photo submission, and inter-professional consultations. Separate payment codes for Internet/telephone consultations between treating and consulting practitioners were created. Chronic care remote monitoring and prolonged preventive care codes were added. Starting July 1, 2019, the beneficiary’s home will be a permissible originating site for telehealth treatment of substance use disorders or a co-occurring mental health disorder.
Documentation requirements have been reduced. Practitioners do not need to re-record elements of the history and physical when there is evidence (i.e., documentation) that they have been reviewed and updated. Practitioners are required to document that they have reviewed and verified the chief complaint(s) and history that was already recorded by ancillary staff or the patient. Practitioners do not need to document the medical necessity for furnishing visits in the home instead of the office.
Risk Management Issues
Documentation
Documentation is always an important patient safety/risk issue. Documentation is sometimes the only form of communication amongst providers and with staff, and is almost always the only communication with CMS and other reimbursing entities. It is one of the most, if not the most, significant issue for supporting and defending care. Always remember the maxim: if it is not in the chart, it did not occur.
Telemedicine, remote, and virtual care will evolve some of its own “feel” because they are new fields that are different from conventional office-based practice. However, the basic rules are the same. Be sure to document date, time, means of communication, use of interpreters, consent, review of chief complaint and history and physical, assessments, treatment planning, medication, referrals, prescriptions, follow up, and other relevant medical information.
Consent
Consent has always been the cornerstone of good medical care and is a fundamental patient right. The recent CMS changes have not changed that, but they have expanded their application. When an inter-professional consultation is obtained via telephone/internet/electronic health record, the services are being obtained without the beneficiary patient present (to the consultant). This means that the patient must be informed of the consultation, give consent, and documentation of the same should be done.
Conclusion
CMS recognizes that the increasing use of digital technology has changed the delivery of care and requires corresponding changes in reimbursements. This is just a brief overview of the variations on age-old risk issues like documentation and consent that these changes bring. We recommend that you further research these and other changes so that you may continue to provide the best patient care and outcomes in your practice.
If you are a CAP member planning to start a telemedicine practice, it is important to contact CAP’s Membership Services Department at 800-610-6642 to discuss coverage and special instructions. For other information, please go to CAP's website at: https://www.CAPphysicians.com/articles/telemedicine-risk-management-strategies.
Michael Valentine is a Senior Risk Manager for CAP. Questions or comments related to this article may be directed to mvalentine@CAPphysicians.com.